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Chikungunya fever: An emerging disease in the Caribbean and Americas
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Chikungunya means “that which bends up” in the Makonde African dialect and is an acute febrile illness that usually is associated with severe joint pains and rash. It is caused by an arbovirus that is transmitted through the bite of the Aedes agypti or Aedes albopticus mosquito and develops after an incubation period of 2 to 10 days. This illness is now rapidly emerging in the Americas.
On Dec. 6, 2013, the first two cases of local transmission were identified on the French side of Saint Martin, with 66 confirmed cases rapidly reported. As of Nov. 4, the CDC, in collaboration with the Pan American Health Organization, had identified almost 800,000 cases in the Caribbean and the Americas. Epidemic chikungunya now has been declared in many countries and/or territories throughout this region (see map).
Celia DC Christie
Roxanne Melbourne-
Chambers
Clinical manifestations
The illness may be biphasic or triphasic. Clinical features in the first phase include sudden onset of high fever greater than 102˚F lasting for about 2 days, associated with knife-sharp, multisite muscle and joint pains involving the large joints of the knees, shoulders, elbows and ankles; the small joints of the wrists, ankles, hands and feet; as well as the spine, lower back and pelvis. The involved joints may become oedematous, with incapacitating joint swelling. Joint and muscles pains are excruciating; affected persons require assistance with standing, sitting, walking and may find it challenging to use their hands to complete simple everyday procedures (eg, holding a cup, brushing teeth, combing hair or writing with a pencil).
Countries and territories in the Americas where chikungunya cases have been reported: Anguilla, Antigua and Barbuda, Aruba, Bahamas, Barbados, Brazil, British Virgin Islands, Cayman Islands, Colombia, Costa Rica, Curacao, Dominica, Dominican Republic, El Salvador, French Guiana, Grenada, Guadeloupe, Guatemala, Guyana, Haiti, Jamaica, Martinique, Montserrat, Nicaragua, Panama, Paraguay, Puerto Rico, Saint Barthélemy, Saint Kitts and Nevis, Saint Lucia, Saint Martin, Saint Vincent and the Grenadines, Sint Maarten, Suriname, Trinidad and Tobago, Turks and Caicos Islands, United States, US Virgin Islands and Venezuela.
Adapated from cdc.gov
A generalized maculopapular rash also occurs and is associated with severe itching. Other common manifestations include syncope, malaise, severe weakness, headaches, dehydration, extreme thirst, vomiting, diarrhea and urinary incontinence. Uncommon manifestations are myriad and may include uveitis, renal failure, meningitis and encephalitis. The illness may abate after about 10 days to 2 weeks, only to return with a recrudescence of severe joint symptoms, including severe arthralgia and arthritis, of the large and small joints with malaise and prostration. These symptoms may gradually resolve after a few months, or may continue for another year, or even up to 5 years. Chikungunya is more severe in the very young, elderly, pregnant women and in those with underlying diseases who have a greater risk for mortality.
Continual spread
The attack rate of chikungunya virus in families and communities may be high in susceptible populations. As of Nov. 4, the CDC has reported 1,627 chikungunya cases in the US, including 1,598 in returning travelers from the Americas and 11 locally transmitted cases in Florida. The CDC warns that the virus “continues to spread with no sign of slowing down.” Physicians must therefore be astute in taking a good travel history in patients with high fever and joint pains and recognize and diagnose chikungunya fever in adults and children who are returning to the US from endemic countries or territories. Confirmatory laboratory tests include PCR testing in the first week and EIA testing after day 8. Both are often positive for chikungunya virus in involved cases. Physicians should follow-up with reporting suspect cases to facilitate necessary public health interventions.
There is no treatment or currently licensed vaccine to prevent chikungunya. Treatment modalities are supportive and may include antipyretics and pain relievers, fluids and bed rest. Aspirin is not recommended because of the possibility of bleeding. Anti-inflammatory agents (eg, naproxen) may be utilized for joint symptoms.
Public health interventions during travel to these areas must therefore focus on preventing transmission to protect individuals by using air conditioning or window/door screens to keep mosquitoes outside, reducing the mosquito breeding sites by emptying standing water from containers such as flowerpots or buckets, wearing long-sleeved shirts and long pants and using insect repellents. Measures to protect the community include fogging and environmental clean-up of mosquito breeding sites.
References:
CDC. Chikungunya virus. Available at: www.cdc.gov/chikungunya. Accessed Nov. 13, 2014.
Sebastien MR. Indian J Pediatr. 2009;76:185-189.
For more information:
Celia DC Christie, MBBS, DM (Paed), MPH, is a pediatrician and infectious diseases specialist, who trained at Yale University. For the past 15 years, she has worked in the Department of Pediatrics (Child) and Adolescent Health, University of the West Indies and University Hospital of the West Indies, Kingston, Jamaica. She can be reached at Celia.ChristieSamuels@uwimona.edu.jm.
Roxanne Melbourne-Chambers, MBBS (Hons), DM (Paed), is a pediatrician/pediatric neurologist in the Department of Child and Adolescent Health, University of the West Indies and University Hospital of the West Indies, Kingston, Jamaica. She can be reached at roxanne.melbournechambers@uwimona.edu.jm.
Disclosure: Christie and Melbourne-Chambers report no relevant financial disclosures.